Many Psoriatic Arthritis Patients Are Undertreated

A study looks at treatment trends and dissatisfaction rates in psoriasis patients.

08/30/2013 | By Jennifer Davis

The study also found that when it came to biologics (used by approximately 30 percent of respondents at any one point in time), patients who discontinued them said they did so because of side effects, lack of effectiveness or inability to get insurance coverage for them. The U.S. Food and Drug Administration approved etanercept for treatment of PsA in 2002; other biologics followed.

“Sometimes, it’s about educating patients about the medication and understanding the side effects they are experiencing,” Dr. Armstrong says. She says studies have shown psoriasis and PsA patients are at a greater risk of other conditions like heart attack, stroke, diabetes, hypertension and metabolic syndrome and that risk increases based on the severity of the psoriasis.

She says that in the case of psoriatic arthritis, if it’s left untreated or undertreated significant debility can develop. “Their joints can undergo significant deformities so they can’t open a door or even drive because their hands can’t hold a steering wheel. For people that are undertreated, it affects their quality of life because they can’t get up and do what they want to do,” she says.

Christopher T. Ritchlin, MD, professor and chief of the division of allergy, immunology and rheumatology at the University of Rochester Medical Center in New York, is one of three co-founders of the hospital’s Psoriasis Center. He says in his clinical practice, discontinuation of biologics is rarely a result of ineffectiveness because most PsA patients respond to them at a rate that’s greater than what is typically seen with RA patients.

“I think biologics work well for patients with PsA because it’s a different disease than RA,” he says, adding that tumor necrosis factor (TNF) – the inflammatory molecule targeted by biologics like etanercept and adalimumab – may play a bigger role in PsA than in RA.

But Dr. Ritchlin says it is increasingly common for patients to have difficulty getting insurance coverage for biologics, especially early in the disease, when many providers want to first try less expensive treatments, such as methotrexate, even though Dr. Ritchlin says data shows they may not work as well for PsA.

He advises patients to keep an open line of communication with their doctor.

“Talk with your dermatologist and rheumatologist about what is happening with your skin and joints, so things can be done to try and make it better,” Dr. Ritchlin says.

About half of all patients with psoriasis and psoriatic arthritis (PsA) are dissatisfied with the treatment they are getting, according to a new study published online in August in JAMA Dermatology. Moreover, the study found a large percentage of study participants are either undertreated or not getting any treatment at all.

Psoriasis – an autoimmune, inflammatory skin disease – causes patients to develop painful red, scaly rashes. Up to 30 percent of patients with psoriasis have or will develop psoriatic arthritis, in which the joints are also affected, causing pain, swelling and potential damage. Treatment for both PsA and psoriasis includes topical creams (applied to the skin), phototherapy (light therapy), oral drugs such as methotrexate, and/or biologics such as etanercept (Enbrel) and adalimumab (Humira).

“I think the numbers are significant especially for the psoriatic arthritis population,” says lead author April W. Armstrong, MD, assistant clinical professor of dermatology and director of the Clinical Research Unit at the University of California – Davis in Sacramento. “For people suffering from psoriatic arthritis, if they are unsatisfied with their treatments it’s often because they have noticeable symptoms. And that is something that is concerning because the symptoms they have often correlate with X-ray findings for joint destruction. And once joint destruction occurs that is irreversible.”

For the study, researchers analyzed data from 13 surveys – conducted by the National Psoriasis Foundation between 2003 and 2011 – of 5,604 patients with psoriasis or PsA. The researchers found:

Depending on the year the survey was taken, 23 to 49 percent of patients with mild and moderate psoriasis said they were untreated, and 9 and 30 percent of those with severe psoriasis said they were untreated.

Among those who were treated, 29.5 percent of patients with moderate psoriasis and 21.5 percent with severe psoriasis were only using topical treatments. Among the top three reasons, according to respondents: Topicals have fewer side effects than other medications, their “disease is not serious enough” for other medications, and their doctor would not prescribe other treatments.

Overall, 45.5 percent of PsA patients and 52.3 percent of psoriasis patients reported they weren’t satisfied with their treatment.

The study also found that when it came to biologics (used by approximately 30 percent of respondents at any one point in time), patients who discontinued them said they did so because of side effects, lack of effectiveness or inability to get insurance coverage for them. The U.S. Food and Drug Administration approved etanercept for treatment of PsA in 2002; other biologics followed.

“Sometimes, it’s about educating patients about the medication and understanding the side effects they are experiencing,” Dr. Armstrong says. She says studies have shown psoriasis and PsA patients are at a greater risk of other conditions like heart attack, stroke, diabetes, hypertension and metabolic syndrome and that risk increases based on the severity of the psoriasis.

She says that in the case of psoriatic arthritis, if it’s left untreated or undertreated significant debility can develop. “Their joints can undergo significant deformities so they can’t open a door or even drive because their hands can’t hold a steering wheel. For people that are undertreated, it affects their quality of life because they can’t get up and do what they want to do,” she says.

Christopher T. Ritchlin, MD, professor and chief of the division of allergy, immunology and rheumatology at the University of Rochester Medical Center in New York, is one of three co-founders of the hospital’s Psoriasis Center. He says in his clinical practice, discontinuation of biologics is rarely a result of ineffectiveness because most PsA patients respond to them at a rate that’s greater than what is typically seen with RA patients.

“I think biologics work well for patients with PsA because it’s a different disease than RA,” he says, adding that tumor necrosis factor (TNF) – the inflammatory molecule targeted by biologics like etanercept and adalimumab – may play a bigger role in PsA than in RA.

But Dr. Ritchlin says it is increasingly common for patients to have difficulty getting insurance coverage for biologics, especially early in the disease, when many providers want to first try less expensive treatments, such as methotrexate, even though Dr. Ritchlin says data shows they may not work as well for PsA.

He advises patients to keep an open line of communication with their doctor.

“Talk with your dermatologist and rheumatologist about what is happening with your skin and joints, so things can be done to try and make it better,” Dr. Ritchlin says.